Avenue of 444 Flags Foundation, 2619 East State Street, Hermitage, PA 16148 – 724-346-3818
Authorization and Acknowledgment For Placement of Cremated Remains In an Ossuary
The Avenue of 444 Flags Foundation has created the Veterans Left Behind Project in an effort to provide a proper resting
place for the cremated remains of honorably discharged servicemen and servicewomen and their families that are unclaimed in
funeral homes or crematories, and those whose families cannot afford the costs of interment. This Authorization and
Acknowledgment For Placement of Cremated Remains In an Ossuary (“Agreement”) allows Avenue of 444 Flags Foundation
and the Veterans Left Behind Project to: accept the cremated remains of the Deceased identified below; place them in an
ossuary in Hillcrest Memorial Park, Hermitage, PA; and memorialize him or her through online obituaries or tributes.
Please provide information regarding the Deceased:
___________________________________________________ _______________ _______________
Name of Deceased
Date of Birth
Date of Death
Please provide information on your relationship to the Deceased:
________ FAMILY – If you select family, please identify that you are the Legal Authorizing Agent of the Deceased.
Initials
As the Authorizing Agent, you represent that you have the authority and legal right to determine and
arrange for the final disposition of the cremated remains of the Deceased.
________ FUNERAL HOME – If you select Funeral Home, you represent that you have met ALL state
Initials
requirements in order to identify and notify the Authorizing Agent of the Deceased.
Please provide your Authorization, Acknowledgement, and Release:
I/We understand that the cremated remains provided may be comingled with the cremated remains of others
unless I/we arrange with the Avenue of 444 Flags Foundation to have them interred in a separate container.
I/We understand that this process is permanent and irreversible.
I/We understand that the Avenue of 444 Flags Foundation will be the only party able to place any memorialization at the
site of the interment.
I/We hereby release and hold harmless The Avenue of 444 Flags Foundation, the Veterans Left Behind Project, and
Hillcrest Memorial Park, their agents, officers, and employees from any and all actions, claims, demands, damages,
costs, and liability, including but not limited to those arising out of emotional or physical injury, distress or trauma
attributed to any services provided to those parties for the Deceased.
I/We hereby understand, accept, and acknowledge all of the terms in this Agreement:
___________________________________________ ______________________ __________ ________
NAME Authorizing Agent
Signature Authorizing Agent
Relationship
Date
___________________________________________ ______________________ __________ ________
NAME Authorizing Agent
Signature Authorizing Agent
Relationship
Date
___________________________________________ ______________________ __________ ________
NAME Authorizing Agent
Signature Authorizing Agent
Relationship
Date
WITNESS:
___________________________________________ ______________________ __________
NAME
Signature
Date
Please make sure the following items are included with this Agreement:
_______ Signed Authorization and Acknowledgment For Placement of Cremated Remains In an Ossuary
_______ Copy of DD 214 Form or other paperwork showing branch of service and honorable discharge
_______ Copy of a Burial Permit and/or Cremation Permit
_______ Copy of any available obituary and/or biographical information or photos of the Deceased
Please contact us with any questions you may have about the contents of this form including applicable state requirements for
abandoned cremated remains: info@avenueofflags.com (724)-346-3818